A New War

Don't Wait Till It's Too Late to Prepare for Bioterrorism

Cover Story --March 2000

By Johanna Franke Associate Editor

Imagine a mild, fall Saturday evening in Austin. More than 85,000 football fans fill Darrell K. Royal-Texas Memorial Stadium to watch The University of Texas Longhorns take on their latest opponent. A breeze blows from east to west.

During the first quarter of the game, an unmarked truck drives south on the upper deck of IH-35 toward San Antonio. Inside, terrorists release an aerosol of powdered anthrax over 30 seconds as the truck passes the stadium. The invisible, odorless anthrax cloud rides the breeze through the stadium, parking lots, and the rest of the UT campus. It invades the State Capitol grounds and the businesses in downtown Austin.

Within hours, the truck drivers leave the country, and within 10 days, nearly 5,000 people die from the anthrax attack.

Could this happen?

It very well could, says Thomas V. Inglesby, MD, an assistant professor in the Division of Infectious Diseases at Johns Hopkins University School of Medicine. He presents a detailed anthrax case study on which the above scenario was based in the July-August 1999 issue of Emerging Infectious Diseases (www.cdc.gov/ncidod/EID/vol5no4/inglesby.htm).

Upon hearing this scenario at a conference last year, Dennis Perrotta, PhD, chief of the Bureau of Epidemiology at the Texas Department of Health (TDH), says he was struck by the total social disruption a bioterrorist attack like this could cause . "A whole area of a city, like downtown Austin, would die. Nobody would want to live in that area or operate their businesses or the university down there. People would no longer visit the Capitol or trade with Austin companies," Dr Perrotta said. "The disruption to the city would be more than what would happen with just the ill and the dead. People could no longer deal with the fear that this would happen again, and they would move."

To deal with an event like this, cities need to develop teams that can respond to a new kind of terrorism -- teams for which physicians will be the defensive starters. The Texas Medical Association is trying to educate physicians for this important role. With $14,000 from the American Medical Association and the American Public Health Association, TMA held three bioterrorism workshops last year, one of which featured Dr Perrotta as the main speaker. State and federal government agencies also are stepping up efforts to inform and train emergency response teams.

"On a federal level, bioterrorism and weapons of mass destruction are really at the top of planning right now," said Steve Harris, MD, Health Authority for the City of Austin and Travis County. "I was very surprised to hear how big a deal this is, but this is a big deal."

The threat

Unlike nuclear or chemical attacks, biological attacks most likely would go unnoticed unless announced by their perpetrators. They would not resemble a mass casualty explosion or a chemical event, such as the 1995 incident in which sarin nerve gas was released in a Tokyo subway by the Aum Shinrikyo cult, killing 12 people and sending more than 5,000 to hospitals for treatment. A chemical response would be handled much like a very serious hazardous materials spill at the local level, but biological events would be noticed by physicians when patients began filling emergency rooms and clinics.

"People won't be gasping and collapsing like they would in a chemical attack. It won't be immediately evident," Dr Perrotta said, "There will be no 9-1-1 call for this, and it will show up days to weeks later, depending on the agent, with an increasing number of people who are sick with flu-like symptoms."

The relatively simple production of these biological agents makes them appealing to terrorists, says general surgeon David Vanderpool, MD, chair of the Dallas County Medical Society (DCMS) Board of Health, which is studying bioterrorism among other topics. The four most popular bioterrorism agents are anthrax, plague, botulism, and smallpox (see "Biological Agents That May Be Used by Terrorists"). They are highly virulent, able to withstand harsh environmental conditions, and easy to produce in large quantities and in a suitable particle size.

"What if someone were to put smallpox in the ventilation system during a big gathering at Reunion Arena or during Thanksgiving or Christmas at DFW Airport? They might infect tens of thousands of people," Dr Vanderpool said. "We don't have a way to prevent it. We don't even have smallpox vaccine in large quantities anymore."

Though most people think smallpox was eradicated about 20 years ago, two known cultures still exist. One is at the Centers for Disease Control and Prevention (CDC) in Atlanta and the other is in Russia outside of Moscow. With the dissolution of the Soviet Union, medical military intelligence officials worry that thousands of Soviet biological weapons scientists, who are no longer getting paid because of Russia's economy, will pass on their knowledge to countries such as Iraq and North Korea. This fear is so great that the US government is paying Russian scientists' wages with American tax dollars to conduct other types of research and prevent them from working for terrorists, Dr Perrotta says.

So far, the only known act of bioterrorism on American soil took place in a small Oregon town in 1984. Members of a religious cult, the Rajneeshee, contaminated salad bars in 10 restaurants with Salmonella typhimurium in an effort to sway a local election. More than 750 people, including two county commissioners, became ill.

Lately, hoaxes have made headlines, such as the 20 threatening letters claiming to contain anthrax that were sent to abortion clinics nationwide in January. The first US indictment involving the mailing of a substance alleged to be anthrax also happened in January in Texas. Stephen Cutler, a 27-year-old Dallas emergency technician, mailed vials of water to the postal processing center in Coppell in December 1998 and to a Dallas apartment complex in January 1999. He labeled the vials as anthrax.

These hoaxes are not being taken lightly. The Clinton administration has called biological and chemical terrorism the nation's No. 1 security threat. Mr Cutler has been charged with two counts of threatening to use a weapon of mass destruction and one count of making threatening communications through the Postal Service. If convicted on all counts, Mr Cutler could be imprisoned for up to 30 years and face a fine of up to $1 million.

"Somebody asked me, 'So sending water is now a felony?' and I said, 'You've missed the point big time,'" Dr Perrotta said. "The disruption of society is a big deal."

Physician frontlines

For a physician, the results of a biological attack would be similar to the flu epidemic the United States and some European countries experienced in January, except the epidemic would be confined to one or two urban areas at the most, says Donald Gordon, MD, PhD, a San Antonio emergency medicine specialist. Most physicians wouldn't be able to tell the difference between biological attack victims and flu sufferers until patients started dying, he adds.

"Physicians have a big problem because they're inundated with all kinds of illnesses anyway," Dr Gordon said. "Depending on their specialties, unless they see something weird with frequency, they're going to be hard-pressed to figure out that it's bioterrorism."

Most physicians have never seen a case of anthrax, plague, or other infectious disease caused by biological agents, Dr Vanderpool says. "No one on the DCMS Board of Health has seen smallpox except for one physician who went out of his way many years ago to view a case in India," he said. "We may not diagnose it because we've never seen it."

Emergency medicine physicians probably will be the first to notice a large number of strange patient presentations, says Dr Gordon, who has taught courses on bioterrorism through the Department of Medical Technology at The University of Texas Health Science Center at San Antonio since December 1997. "If a cluster of patients come in with the flu in July, and it doesn't make any sense to the physicians, then it's time to notify the health department."

Physicians in areas with local health departments are encouraged to call those departments, who will then notify TDH. Those without local health departments may call TDH's infectious disease reporting line at (800) 705-8868. For convenience, this line also has the technology to connect physicians with their local health departments. Physicians should contact TDH before calling the CDC, as the CDC has no authority to come into Texas unless invited by the state health commissioner. Reporting infectious diseases to TDH is an exception to patient-physician confidentiality laws, Dr Perrotta says.

Physicians should not hesitate to call when they feel something is off because time is of the essence in a biological attack, Dr Perrotta emphasizes. "Physicians' opinions are important, and when something makes the hair on the backs of their necks stand up, that's when they should call the health department," he said. "They shouldn't wait for confirmation. We trust physicians' judgments and we will follow up from there. We don't mind if it's just the flu; that's still a public health problem we need to investigate."

In the case of anthrax, taking 10 days to come up with the right diagnosis could cost hundreds of lives because 80% of people who develop severe anthrax symptoms will die. In addition to flu-like symptoms, inhalation anthrax victims often have widened mediastinums that will show up on x-rays. This should prompt a call to the health department.

From there, TDH takes over. "Physicians can tell us a lot of clues, but it's our job to identify the source [of the disease] and to make recommendations on what to do about it," Dr Perrotta said. For a bioterrorist event, TDH will conduct a regular epidemic investigation, which includes lab work and finding similarities among the victims.

TDH officials then have the authority to take a variety of control measures or directly request the activation of the Governor's Disaster Response, which would include all state agencies and the National Guard.

Texas prepares

"I think it's safe to say that Texas is further along than most states," Dr Perrotta said. But the United States, as a whole, is poorly prepared to respond to any kind of terrorism attack, he adds.

The federal government realizes this and began doing something about it with the Nunn-Lugar-Domenici Amendment to the National Defense Authorization Act of 1997. Under this provision, $9.2 million was awarded by the US Department of Health and Human Services (HHS) to 25 cities to develop Metropolitan Medical Response Systems (MMRSs). Houston, Dallas, and San Antonio were three of the cities that received funding to create their own teams, which are supposed to provide initial, on-site response and safe patient transportation to hospital emergency rooms during nuclear, chemical, or biological terrorism attacks. They have been trained to provide medical and mental health care to victims of attacks as well as prepare to move victims to other regions should local health resources be exhausted.

In 1998, President Clinton ordered expanded efforts to protect against biological and other unconventional attacks, especially bioterrorism directed at civilian populations, and $158 million was added to the budget for HHS efforts. President Clinton's fiscal year 2000 budget proposes additional funds for the HHS antibioterrorism initiative, increasing the investment to $235 million. HHS would use this money to:

Improve the nation's public health surveillance network to be able to detect quickly, based on the appearance of disease symptoms, whether a biological agent has been released.

Strengthen the capacities for medical response, especially at the local level.

Create and maintain a stockpile of pharmaceuticals for use if mass treatment is needed.

Expand research into the disease agents that might be released to develop quick methods for diagnosing these diseases and improve treatments and vaccines.

Ultimately, HHS will establish 120 MMSTs, 12 of which will be in Texas. Austin, Corpus Christi, Fort Worth, El Paso, Arlington, Irving, Garland, Amarillo, and Lubbock will join San Antonio, Houston, and Dallas in preparing for terrorism attacks. Austin, El Paso, and Fort Worth recently received their federal funding.

In San Antonio, city officials are preparing through training and drills, Dr Gordon says. In October, city agencies and some of the private emergency medical services (EMS) companies simulated a sarin nerve gas release at the Alamodome.

At press time, Houston was about to undergo a field exercise for a chemical event in front of US Public Health Service and Department of Defense officials. The city probably will complete a biological agent drill in the fall, says David Persse, MD, physician director of Emergency Medical Services for the City of Houston.

Like most cities, Houston's biggest challenge in preparing for any kind of terrorist attack was coordinating the city's various hospitals, which meant convincing hospital administrators that they should spend time and resources on terrorism, Dr Persse says. But with help from the Harris County Medical Society, city officials were able to share their concerns with Houston hospital chiefs of staff, who then went knocking on their administrators' doors.

"At the second meeting, all these chiefs of staff brought many of their administrators with them," Dr Persse said. "We suddenly had eight large hospitals that wanted to actively participate in the overall regional plan."

Parkland Memorial Hospital in Dallas was featured in the January 10 Dallas Morning News for its terrorism preparation. Anticipating terrorism acts in conjunction with new millennium activities, Parkland stockpiled drugs to counter chemical and biological attacks. Parkland had enough medications on hand to treat 1,000 potential victims -- an expensive undertaking, considering these medications have limited shelf lives. More than 120 nurses and 15 physicians had trained to protect themselves from contaminated patients. But even Parkland's president, Ron Anderson, MD, said in the article, "If we have 5,000 or 6,000 casualties, we're unprepared. We're not even close."

As a high-tech hub, a state capital, and the home of a presidential candidate, Austin could be a potential terrorism target, Dr Harris says.

The city's Interagency Disaster Council and Terrorism Planning Group meet on a regular basis and work together to coordinate EMS, fire, police, and public health agencies. The groups have drafted a city weapons-of-mass-destruction policy and recently staged a mock bioterrorism attack on an outdoor music festival, Dr Harris says. During the simulation, a helicopter flying over the concert released plague on the audience, which eventually led to thousands of casualties, quarantining of the county, and closure of IH-35.

Though HHS funds have gone to the more populated areas of Texas, any town could be a target for a terrorist attack, Dr Harris says. "Frankly, any city is at risk if somebody really wants to make a point."

Renewing relationships

Despite all the federal funding for training, physicians aren't receiving the bioterrorism education they need, Dr Vanderpool says. "The federal government has spent a lot of money trying to get the fire department, the police, and the National Guard to deal with these sorts of things, but the person who has been left out of the loop is the practicing doctor," he said. "That person is going to be the one who is most likely to see the cases first."

Some Texas cities have earned additional grants that city officials hope to use for physician and other health care worker education. Dr Vanderpool, on behalf of the DCMS Board of Health, is trying to build state legislative support for this kind of education as well. In January, he testified before the Senate Interim Health Committee.

"We want to get the government looking at the medical profession to be involved in this because we're the ones who are going to have to fight the war, at least as far as diagnosis and treatment," Dr Vanderpool said. He has asked the Texas Legislature to provide leadership and funding toward establishing and maintaining community-wide, active disease surveillance systems that would include physicians' offices, clinics, and emergency rooms.

Even if physician education is available, will physicians be interested? Dr Persse isn't too sure. "Getting awareness out to the physicians will be the most difficult aspect because physicians have so many other things pressing them throughout the day," he said. "When you ask them to prepare for when the sky is falling, they say, 'I haven't got time today.'"

Despite these challenges, public health officials are pleased that HHS bioterrorism efforts are opening up the working relationships among various agencies, hospitals, and physicians.

"They're revitalizing the long-decaying infrastructure that builds the communication among doctors, hospitals, and public health departments around the country," Dr Perrotta said. "When those relationships and bridges are already constructed and well traveled, it greatly improves the chance that when something odd does happen, the system can react quickly and correctly to save lives."